Executive Summary

Improving Patient Flow and Reducing Emergency Department Crowding

The Need to Address Emergency Department Crowding

Although you, as a hospital or department leader, are responsible for overseeing performance across a number of dimensions, there are several reasons why addressing emergency department (ED) crowding should be at the forefront of your organization's improvement efforts:

ED crowding can be mitigated by improving patient flow throughout the hospital.

The purpose of this guide is to present step-by-step instructions for planning and implementing patient flow improvement strategies.

Forming a Patient Flow Team

The importance of creating a patient flow improvement team—and giving careful thought to its composition—cannot be underestimated. Numerous studies have shown the benefits of creating a multidisciplinary team to plan quality improvement interventions. We recommend that, at a minimum, your team include a team leader (i.e., day-to-day leader), senior hospital leader (e.g., chief quality officer), ED physicians and nurses, ED support staff (e.g., clerks, registrars), representatives from inpatient units, and a research/data analyst. It is important to include representatives from all departments that will be affected by your strategy, individuals who will serve as champions for your strategy, and those who may oppose your strategy so that their concerns may be heard.

Measuring ED Performance

Measurement is a fundamental tool to identify and eliminate variation in clinical processes. Data also can be used to show that ED crowding is not just an ED problem, but one that requires hospital-wide solutions. Currently, hospitals are required to report several ED quality measures—for example, the core measures—and new measures are scheduled to start affecting hospital payment in 2013 and beyond (e.g., median time from ED arrival to ED departure). We recommend all hospitals begin collecting data on those measures now.

Identifying Strategies

Selecting the right strategy is paramount for any successful intervention. Hospitals that devote sufficient time up front to careful selection of a strategy often save time in the long run by avoiding having to make major adjustments midstream. We recommend that your team take the following steps before selecting your improvement strategy:

Identify the most likely causes of the specific problems you face.

Review available materials that describe what other hospitals have done to improve patient flow.

Consider your resources.

Preparing to Launch

Once the strategy is selected, we recommend that hospitals create a road map for the implementation process. An implementation plan should be completed by the team and can help:

Identify your goals and strategies.

Plan your approach.

Estimate the time and expenses associated with implementation.

Identify performance measures.

Once completed, we recommend that you share your implementation plan with other hospital and department leaders to ensure that they (1) are aware of the efforts underway and (2) understand the timeline, budget, and resources that will be needed.

Facilitating Change, Anticipating Challenges

Facilitating change often involves anticipating common challenges and taking steps to forestall them. We recommend several strategies for addressing those challenges.

Recommended Approaches to Addressing Implementation Challenges

Challenge

Recommended Approach

Rationale

Culture change

Constant reinforcement of the strategy by leaders.

Signals to staff that the improvement strategy will become standard procedure.

Staff resistance

Staff education.

Provides staff with the capabilities and knowledge to carry out the strategy.

Staff resistance

Post-implementation adjustments reflecting user recommendations.

Signals responsiveness to staff concerns.

Staff resistance, culture change, and lack of staffing resources

Use of Lean quality improvement methods.

Fosters a team environment.

Lack of staffing resourcesStaff resistance

Robust data collection.

Provides concrete evidence of need for action; demonstrates success to hospital leaders and frontline staff; is crucial in securing an executive champion.

Sharing Results

Sharing results internally and externally is the key to sustainability and spread. Widely reporting the results of multi-unit and department initiatives helps create a culture of transparency and openness. Units given the opportunity to compare their performance relative to other units will develop a healthy competition to improve. We recommend the use of ED dashboards to provide a snapshot of key process variables of particular interest to internal stakeholders.

Though not all hospitals can participate in a formal collaborative, we recommend that all hospitals build momentum by sharing their results with external stakeholders through community partnerships, written publications, and conference presentations. Some examples of potential outlets for sharing results include: community social service organizations that work with the hospital, other hospitals within a system or in the hospital's metropolitan or State hospital association, local newspapers and blogs, trade publications (e.g., Hospitals & Health Networks, Modern Healthcare), peer-reviewed journals (e.g., Joint Commission Journal on Quality and Patient Safety, Journal of Emergency Medicine, Journal of Emergency Nursing), and professional societies (e.g., Society for Academic Emergency Medicine, American College of Emergency Physicians, and Emergency Nurses Association).